This forearm fistula – created where a large branch joins the cephalic vein several inches above the wrist – was released for use five weeks after creation. At ten months you can see the vein growing all the way up the arm. In truth, this fistula could be cannulated in the upper arm as well as in the forearm, and there would be zero recirculation with needles ten inches apart.
This transposed basilic fistula was created from the outflow vein of a failed wrist fistula, and was released for use within three weeks.
This patient's wrist fistula, much revised and redilated over the years, was slowly failing. The basilic vein above it was transposed and is currently usable. When the fistula in the forearm finally fails, the upper part will be reconnected to the brachial artery at the elbow.
This transposed basilic fistula was created after failure of an unused left wrist fistula. "I've been on dialysis since I was fourteen, and this is the best decision I've made"
This wrist fistula was created in 1974, and reportedly has required no intervention since that time. If you were on dialysis, would you want an access that worked for 30 years without a problem?
This basillic fistula was created from the toughened outflow vein of a failed forearm graft.
Another basilic fistula created from the toughened outflow vein of a failed forearm graft.
The cephalic component of this antecubital fistula did not develop, but the basilic vein did, and was moved from the inside of the arm to the front to form an excellent fistula.
A fistula created from the vein of the thumb and the dorsal branch of the radial artery is called a “snuffbox” fistula, so called because the space between the extensor tendons of thumb forms a depression known as the anatomic snuffbox. This fistula is the longest fistula possible – in this case the vein goes all the way up the arm. Because the artery is so small so far out though, this fistula is prone to failure.
A mature snuffbox fistula.
The transposed basilic fistula pictured above demonstrates that even patients with thicker and shorter arms can have a fistula.
This superficialized upper arm cephalic fistula was sizable, superficial and had adequate flow, but was difficult for dialysis personnel to palpate, leading to multiple misdirected cannulations and associated infiltrations. An ultrasound-assisted digital photo diagram was created to help guide cannulation and make everybody's day better.
This transposed basilic fistula is only three weeks old and the incision is still healing but the fistula itself is usable. The basilic vein is the largest vein in the arm, and frequently does not need further time to grow to a usable size. The natural tissues also heal quickly. We have cleared basilic fistulas for use within ten days from creation when necessary.
This mighty transposed basilic fistula might never have been born. Months earlier, radiologists cleaned out this patient’s clotted left arm veins, dilated the narrowings, and put the patient on blood thinners, thus preserving the left arm for use. Later, a very usable transposed basilic fistula was created from this once clotted vein.
This forearm fistula is less than three weeks old, and already big enough to use if needed. Is the patient a 25 year-old lumberjack? No, he is 85 years old.
The basilic vein is sometimes huge on the back of the forearm and can be transposed to the front for an excellent fistula
Seldom does Mother Nature leap into your lap with a terrific vein like this. This wrist fistula was ready for use within weeks, and also promises to develop secondary upper arm cephalic and basilic fistula options.
Another basilic fistula.
Fistulas can be created in large arms, but most often they are too deep to use. The advantage of a large arm, however, is that most often the veins have not been ruined by IVs and blood draws. If a fistula develops after a relatively small operation, then moving it to the surface can make sense (below).
The best fistula may not actually be a fistula. This one is a graft. This forearm loop graft
has promoted a huge cephalic vein in the upper arm. Whenever desired, this cephalic vein could be connected to the brachial artery to form an instant fistula. No catheter would be required.
The cephalic vein in the upper arm was superficialized above this wrist fistula, giving much more room for cannulation.
Ultrasound of a radial artery and cephalic vein at the wrist, both suitable for a fistula.
A thigh graft - placed when upper body options are depleted.
A swollen hand on the same side as an active graft or fistula - the result of a blockage in the veins on that side
The left arm is bigger due to a blockage on the same side as an active fistula. The patient needs a procedure to open up the veins again.
This basilic vein on the back of the forearm is not in a convenient place for a fistula, but it can be moved to the front of the forearm, or to the upper arm.
A normal venogram, with the vessels from the right arm coming into the chest (notice the ribs showing faintly in the bottom left side of the photo), and then emptying down into the heart.
The vein going down to the heart has been ruined by the catheter you can see in the x-ray. Compare this picture to #25. If the blockage is not corrected, the patient will have a swollen hand and arm (#26 and #27) and not be able to use that arm for dialysis.
This ultrasound tracing shows good flow in a graft or fistula.